AccountId: 011433970860
ContactId: ec28c2a3-24b9-429c-a0c8-e416fc4ff3a0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 482220 ms
Total Talk Time (AGENT): 231815 ms
Total Talk Time (CUSTOMER): 172932 ms
Interruptions: 1
Overall Sentiment: AGENT=1.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/22/ec28c2a3-24b9-429c-a0c8-e416fc4ff3a0_20250122T18:14_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi [PII], how are you? My name is [PII]. I'm calling because um I'm pregnant and I tried to use my insurance.
[CUSTOMER][NEUTRAL] Um, for ultrasound that they, they, my, my insurance doesn't cover. So now I'm trying to use my gap.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I have the claim number and and everything.
[CUSTOMER][NEGATIVE] And they are just telling me that they don't accept um gap.
[CUSTOMER][NEUTRAL] So, I don't know what to do right now.
[AGENT][NEUTRAL] OK, um, let's look into that for you. And do you have your policy number handy?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, what's that policy number?
[CUSTOMER][NEUTRAL] Give me one second, my policy number is 023543556.
[AGENT][NEUTRAL] 02354356
[CUSTOMER][NEUTRAL] 02354356, yes.
[AGENT][NEUTRAL] And Ms. [PII], would you be able to verify for me, please, your last name and your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and that last name?
[CUSTOMER][NEUTRAL] My last name is [PII].
[AGENT][POSITIVE] Wonderful and then I just need to verify a couple other pieces of information if you could verify with me your mailing address.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect and that phone number on file?
[CUSTOMER][NEUTRAL] The what sorry, [PII].
[AGENT][NEUTRAL] Thank you and then lastly it's just the mailing address.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you, Ms. [PII]. I really appreciate that. Um, so you're saying, and I just wanna make sure I understand this correct, um, that you went to go get your ultrasound at your doctor's office and your insurance isn't paying anything, so you wanna use your gap insurance, but your gap insurance, um, like your provider won't process the gap insurance for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh-huh. Yeah.
[AGENT][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] So, um, you're always welcome to file a claim with us, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It yourself it's always easier if your provider does it but you're very welcome to do it um there's a couple things you would need you would need your um explanation of benefits from your.
[CUSTOMER][NEUTRAL] Yeah, I already, I already have that one. My signa just sent it to me.
[AGENT][POSITIVE] Wonderful.
[CUSTOMER][NEUTRAL] So I can, I can send it to you right now, but also I just called the doctor because the guy that I, I spoke before, he told me that I need a diagnostic code. So they just told me that they don't use that.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, um.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] So we have to have a diagnosis code to or like to file a claim, but there's a form you should be able to ask for it's called a C.
[AGENT][NEUTRAL] MS
[AGENT][NEUTRAL] 1500 CMS 1500.
[CUSTOMER][NEUTRAL] What's that?
[CUSTOMER][NEUTRAL] What's that?
[AGENT][NEUTRAL] Um, so it's like a claim form that the, the doctor's office can give you and it should have everything we need to file and process the claim for you.
[AGENT][NEUTRAL] Uh, C like Charlie, M, S like Sierra, 1500.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sorry, what's that? I don't understand that. I, I.
[AGENT][NEUTRAL] OK, yeah, so there's a form you can ask for from your doctor's office. It's a CMS 1500 CMS 1500 is the name of the form, and it should have all of the information.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What's the, what the name C C you can repeat that C?
[AGENT][NEUTRAL] C like Charlie M S 1500.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, they, they have to provide me that.
[AGENT][NEUTRAL] If they can provide you that form it will have everything you need from them to submit the claim yourself.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So you, you will, you will not pay to them, you will send a check to me.
[AGENT][NEUTRAL] If you file the claim, we'll pay you the money. If the provider files the claim, we pay them the money.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] And with the explanation of benefits, you, you can use that like to have the information that you need.
[AGENT][NEUTRAL] So we do need the explanation of benefits but it will not be everything we need we need that along with the information from the provider.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so it's CMS 1500.
[AGENT][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] And if they told me that they don't have that, what, what I should do.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] If they tell you that they don't have that, I would, I mean.
[AGENT][NEUTRAL] I would
[AGENT][NEUTRAL] Try to tell them like you need a.
[AGENT][NEUTRAL] A diagnosis code in your itemized bill with your procedure codes.
[CUSTOMER][NEUTRAL] Sorry, you can repeat that?
[AGENT][NEUTRAL] I would just like keep reiterating to them that you need a form with your diagnosis code and then you need an itemized bill with your procedure codes if they can't give you that.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] Yeah, because I, I'm calling to them like several times, and they don't, they are not helping me, you know?
[CUSTOMER][NEUTRAL] Nothing.
[AGENT][NEUTRAL] OK, yeah, I, um.
[AGENT][NEUTRAL] I guess I would escalate it up with them if they don't give you that information, but it is the information we need to process the claim, so we do need your procedure codes and how much they were individually charged as well as that diagnosis code.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And they, and they, I feel like they, and they, and they have to give me that information, right? Like that information is open to the, to the clients.
[AGENT][NEUTRAL] Oh, yeah, it should be. There's no reason why they you shouldn't have access to your medical records.
[CUSTOMER][NEUTRAL] OK, and I have another question. um, this EOB that I already have, where I have where I can send it because I just have the billing information in my claim.
[CUSTOMER][NEUTRAL] 7
[AGENT][NEUTRAL] OK, yeah, um, so if you would like I can go ahead and email you our claim form that will have our fax and mailing address but we also have an um.
[CUSTOMER][NEUTRAL] I already have, I already have the claim form. I already have everything. I, I.
[AGENT][POSITIVE] Oh perfect.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So that will have our fax and mailing address on it if you choose to submit it that way we also have an online portal if you want to set up an online account and you could just submit it all from your computer.
[CUSTOMER][NEUTRAL] Yeah, I have here Ola file, so I just put, but it will be like a new claim or you know that it's, it's the same one?
[AGENT][POSITIVE] Oh, you'll just upload it like a whole new claim and you'll be all set that way.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so let me try to call them to see what they say and I will call you back, OK?
[AGENT][POSITIVE] OK, perfect, thank you.
[CUSTOMER][POSITIVE] Thank you bye.